Total Care Integration Project

1. Slide 1 Total Care Integration Project The Kent Center for Human & Organizational Development Cohort 2 Northeast Region Warwick, RI Project Director: Rena Sheehan

2. Our Program • The Model: • The Kent Center, a Community Behavioral Healthcare Organization, established a primary care practice, Primary Care Partners, as a program of The Kent Center. • The practice utilizes a part-time Medical Director, a full time Nurse Practitioner and 2 Medical Assistants to provide the primary care services. • Two nurses from the behavioral health program who are familiar with the clients provide nurse care manager services within the primary care practice and are the connection between the two programs. • The Kent Center contracts with the Kent County YMCA to provide wellness activities facilitated by a Health Navigator both on site at the practice or at the YMCA. • The practice is equipped with a treadmill and recumbent bicycle for consumers who are not ready to attend the YMCA.

3. Our Program • Cumulative Enrollment Targets: • Year 2: 235 consumers • Year 3: 400 consumers • Year 3: 614 consumers • Total Enrollment to Date: 121 • Populations Served: The Total Care Integration Project targets adults with serious mental illness who are receiving services from The Kent Center’s Community Support or Outpatient programs. • Technology: The Primary Care Practice is utilizing Epichart as the electronic health record for all patients. The behavioral health programs have recently started utilizing Clinician's Desktop and DrFirst (e-prescribing) with nurses, MDs and clinical nurse specialists and are in the process of implementing this EHR for all community support program staff.

4. Consultant: Martin Kerzer, DO: Medical Director and PCP Employees: Cheryl Haynes, NP Nancy Hervieux, Medical Assistant Robin Lataille, Medical Assistant Dayna O’Rourke and Joanne Tente, RN Care Managers Our Team

5. Successful Strategies: Wellness • The Kent County YMCA provides Health Navigators who are on site at the practice to engage patients in wellness activities. • The Health Navigators are introduced to consumers by the RN Care Manager who is familiar to the consumer through her work in the behavioral health program. • Health Navigators utilize a technique called Listen First to understand the motivators and barriers to engaging in wellness activities.

6. Successful Strategies: Wellness • Health Navigators work with our clients at the practice and at the YMCA to develop a customized wellness activity plan and assist the clients in remaining engaged in the plan. • There are 10, 3 month YMCA membership scholarships available for program participants who could not otherwise afford the membership. At the end of the 3 month period, the YMCA works with the consumer to provide financial assistance to maintain the membership.

7. Successful Strategies: Wellness • Health Navigator Engagement: • There are currently 13 consumers actively engaged with a Health Navigator, have a YMCA membership and utilize the YMCA regularly. • Twelve (12) clients regularly engage with the Health Navigator and are working toward utilizing the YMCA.

8. Success Story: • A 38 year old female, Kent Center consumer was first seen at Primary Care Partners on Jan. 24, 2012 after being referred by her behavioral health case manager. Her weight at that time was 334lbs. Her complaints were of general stomach pain and a desire to lose weight. • Although initially hesitant about our program, the patient began meeting with the Nurse Care Manager who introduced her to the Health Navigator. The RN Care Manager provided 1:1 nutrition counseling while the Health Navigator worked with her to develop an exercise plan that was comfortable for her. • The consumer began exercising on site at the practice and now exercises there regularly. As a result of her participation in the program, she has achieved a total weight loss of 20 lbs.

9. Slide 9 Plans for the Future Sustainability • Clinical: The RN Care Manager role will be re-examined to identify strategies to move toward a more integrated as opposed to coordinated model that closely aligns with and enhances Medicaid Health Home services. • Administrative: There have been software vendor issues that have required us to bill for services on paper. We are targeted to begin electronic billing the week of May 7, 2012. • Financial: Sustainability relies on achieving a specific payer mix of patients. We will need to examine our original projections and readjust the targets and plan accordingly. Wellness • This quarter, we will begin utilizing wellness groups facilitated by the RN Care Managers to enhance educational programming for consumers served. The group will be a general wellness group focused on the most common issues of weight management, nutrition and managing blood pressure. We are also exploring wellness groups provided by the YMCA.